title: Aldosterone synthase inhibition for the treatment of hypertension and the derived mechanistic requirements for a new therapeutic strategy.
abstract: BACKGROUND
  We describe the clinical investigation of the first generation aldosterone synthase inhibitor, LCI699, in patients with essential, uncontrolled, resistant, or secondary hypertension. LCI699 competitively reduced blood pressure at lower doses yet counterintuitive effects were observed at higher doses.
  
  
  OBJECTIVE
  An extensive endocrine biomarker analysis was performed to better understand the pharmacological mechanism of the drug.
  
  
  RESULTS
  The interference of LCI699 in the renin-angiotensin-aldosterone system occurred with limited target selectivity, as a dose-dependent compensatory stimulation of the hypothalamic-pituitary-adrenal feedback axis was discovered. Thus, LCI699 affected two endocrine feedback loops that converged at a single point, inhibiting the 11β-hydroxylase reaction in the adrenal gland, leading to supraphysiological levels of 11-deoxycortiscosterone. The accumulation of this potent mineralocorticoid may explain the blunted blood pressure response to LCI699.
  
  
  CONCLUSIONS
  Future aldosterone synthase inhibitors may improve their target selectivity by sparing the 11β-hydroxylase reaction and preferentially inhibiting one of the two other enzymatic reactions mediated by aldosterone synthase.
authors.affiliation: aGlobal Development, Critical Care, Novartis Pharma AG, Basel, Switzerland bLong Valley, New Jersey, USA cRiehen, Switzerland.
authors.forename: Christoph D
authors.initials: CD
authors.lastname: Schumacher
authors.forename: Ronald E
authors.initials: RE
authors.lastname: Steele
authors.forename: Hans R
authors.initials: HR
authors.lastname: Brunner
mesh_terms: D000293:Adolescent; D000311:Adrenal Glands / Q000378:metabolism; D000328:Adult; D000368:Aged; D000450:Aldosterone / Q000097:blood; D000959:Antihypertensive Agents / Q000627:therapeutic use*; D015415:Biomarkers / Q000378:metabolism; D001794:Blood Pressure / Q000187:drug effects; D019405:Cytochrome P-450 CYP11B2 / Q000037:antagonists & inhibitors*; D003900:Desoxycorticosterone / Q000378:metabolism; D004311:Double-Blind Method; D000075222:Essential Hypertension; D005260:Female; D006801:Humans; D006854:Hydrocortisone / Q000378:metabolism; D006929:Hyperaldosteronism / Q000188:drug therapy*; D006973:Hypertension / Q000188:drug therapy*; D007031:Hypothalamus / Q000187:drug effects; D007093:Imidazoles / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D011725:Pyridines / Q000627:therapeutic use*; D012084:Renin-Angiotensin System / Q000187:drug effects; D013252:Steroid 11-beta-Hydroxylase / Q000378:metabolism; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D000959:Antihypertensive Agents; D015415:Biomarkers; D007093:Imidazoles; D011725:Pyridines; D003900:Desoxycorticosterone; D000450:Aldosterone; C553306:Osilodrostat; D019405:Cytochrome P-450 CYP11B2; D013252:Steroid 11-beta-Hydroxylase; D006854:Hydrocortisone